U.S. Small Business Administration
OMB Approval No.:3245-0324
Expiration Date: 10/31/2020
Counseling Information Form
Client Number:
Location Code:
Initials of Data Inputter:
Telephone
1
. Name of the Office Providing the Service _______________________________1a. Type of Client:
Face to Face Online
2
. City/State of Office Location_________________________
PART I: Client Request for Counseling
3
.
Client Name
(Name of the person completing the form/representative of the business)
(Last, First, MI)
4. Email
5
.
Telephone 6. Fax
Primary Secondary
7. Street Address/PO Box
(give business address if currently in business
) 8. City 9. State 10. Zip
+4
11
.
I request business counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in
surveys designed to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and
services (Yes No ). I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I
authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services
from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing
management or technical assistance, I waive all claims against SBA personnel, and that of its Resource Partners and host organizations, arising from this assistance.
Use of Information: The information in this form is to be provided by individuals and business seeking technical assistance services from the Small Business Administration
(SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and
management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at
the site of service to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award.
12. Preferred date & time for appointment
Date: Time:
13. Client Signature Date:
PART II: Client Intake (to be completed by all Clients)
14
.
Race
(mark one or more)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
15. Ethnicity
Hispanic or Latino
Not Hispanic or
Latino
16.Gender
Male
Female
17. Do you consider
yourself a person with
a disability
?
Yes No
18. Veteran Status
Service-Disabled Veteran
Member of the Reserve
Veteran
No military, Reserve, or
National Guard service
Active Duty
Member of the National Guard
Spouse of Military Member
19. Referred by?
(Mark all that apply)
SBA District SBDC Other Client
Lender SCORE Educational Institution
Business Owner WBC Local Economic Development Official
SBA Web site VBOC Chamber of Commerce
Internet (please indicate website)
Television/Radio
Magazine/Newspaper
Word of Mouth
Other (specify)
USEAC
Boots to Business
20a. Are you currently in business?
Yes No
(if no, skip to 30)
20b. If yes, are you currently exporting?
If yes to 20b, please go to Appendix A on page 3 to indicate the markets to which your company currently exports (mark all that apply).
Yes
No
21. Name of Business
22. Type of Business
(choose primary category)
Professional, Scientific & Technical Services
Mining Manufacturing Real Estate & Rental & Leasing Management of Companies & Enterprises
Utilities Finance & Insurance Health Care & Social Assistance Agriculture, Forestry, Fishing & Hunting
Information Wholesale Trade Accommodation & Food Services Administrative & Support
Construction Public Administration Arts, Entertainment & Recreation Waste Management & Remediation Services
Retail Trade Educational Services Transportation & Warehousing Other Services (except Public Administration)
23. Business Ownership
– What percentage of
your business is male or female owned?
__________% Male__________% Female
24. Date Business
Started?(MM/YYYY)
25. Do you conduct
business online?
Yes No
26a. Are you a home based business
26b. Are you 8(a) certified?
Yes
No
Yes
No
27a. Total No. of Employees
(full & PT)
27b. Of total employees, how many are
engaged in the exporting aspect of your
business: (Full & PT)
28a. For your most recent full business year, what
were your:
Gross Revenues/Sales $
+Profits/-Losses $
28b. Amount of your Gross Revenues/Sales
related to exporting $
29. What is the legal entity of your business?
Sole Proprietorship Corporation LLC
S-Corporation Partnership
Other (specify) ________________________________
30. What is the nature of counseling you are seeking?
(Choose primary category)
Start-up Assistance (How do I start a
small business?)
Business Plan
Financing/Capital (such as applying
for a loan, building equity capital)
Managing a Business
Human Resources/
Managing Employees
Customer Relations
Business Accounting/
Budget
Cash Flow Management
Marketing/Sales (promotion, market
research, pricing, etc.)
Government Contracting (including
certifications)
Franchising
Buy/Sell Business
Technology/Computers
eCommerce (using the
Internet to do business)
Legal Issues (such as,
Should I incorporate?)
International Trade
Tax Planning
Describe specific assistance requested in the space provided. _____________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
SBA Form 641 (10/24/2017)
CLEAR FORM
U.S. Small Business Administration
OMB Approval No.: 3245-0324
Expiration Date: 10/31/2020
Counseling Information Form
Client Number:
Location Code:
Initials of Data Inputter:
Funding Source:
Part III: Counselor Record
31
.
Client Name
(please use the same name from original 641 Part 1)
(Last, First, MI)
32. Email
33
.
Telephone 34. Fax
Primary Secondary
35. Street Address /P.O. Box 36. City 37. State 38. Zip
+4
39a. Is the client currently in business?
Yes No
(if no, skip to 44)
39b. Is the client currently exporting?
If yes, please turn to Appendix A on page 3 to indicate the markets to which your client currently exports (mark all that
apply).
NoYes
40. Date Business
Started?
41a. Total No. of Employees: (Full & PT)
41b. Of total employees, how many are engaged in
the exporting aspect of client's business?:
(Full & PT)
42a. As of the most recent full business year, what were the client's annual:
Gross Revenues/Sales $_____________________
+Profits/-Losses $
42b. As of the most recent full business year, how much of your client's Gross
Revenues/Sales were related to exporting?
$
43. SBA or Resource Partner Service Contributed to the Following: (Mark all that apply)
Certifications
8(a)
SBIR
Hubzones
Micro loan
SDB
Other (SBIR, SBIC, 7(a) 504, etc)
Other (specify state, local, etc)
SBA Loan Amount $
Non-SBA Loan Amount $
Amount of Equity Capital Received $
No. of Government Contracts/Subcontracts
Annual Value of Government Contracts/Subcontracts Received
$
SBA Financial Assistance
Export Express
Export Working Capital Loan
Community Advantage
44. What was the nature of the counseling you provided the client?
(choose primary category)
Start-up Assistance (How do I start a
small business?)
Business Plan
Financing/Capital (such as, applying
for a loan, building equity capital)
Managing a Business
Human Resources/Managing
Employees
Customer Relations
Business Accounting/Budget
Cash Flow Management
Tax Planning
Marketing/Sales (promotion,
market research, pricing, etc.)
Government Contracting
(including certifications)
Franchising
Buy/Sell Business
Technology/Computers
eCommerce (using the Internet
to do business)
Legal Issues (such as, Should I
incorporate?)
International Trade
Please specify other counseling provided.
45. Referred Client to (mark all that apply):
WBC
SCORE
SBDC
State Trade Agency
USEAC
SBA District Office
Dept of Agriculture
OPIC
Export/Import Bank
Dept of Commerce
Dept of State
U.S. Trade & Development Agency
VBOC
PTAC
Other
46. Type of Session
Face to Face Online Update
Telephone Prep
47. Language(s) Used
English
Spanish
Other (specify)
48. History
New Case
Follow-up
One Time
49. Date Counseled
(MM/YYYY)
50. Counselor(s) Name (If multiple counselors, list lead counselor first and separate
each additional counselor name by a semi-colon):
51. Contact Hours
Total contact hours
that a client received
51b. Prep Hours
Total amount of
preparation spent by all
counselors for a client
51c.Travel Hours Total amount of time it takes to travel to a client's location for counseling
52 Did more than one Counselor participate in this counseling session? Yes__ No__. If yes, how many counselors ________?
53. Counselor’s Notes:
SBA Form 641 (10/24/2017)
2
OMB Approval No.:3245-0324
U.S. Small Business Administration
Expiration Date: 10/31/2020
Counseling Information Form
Client Number:
Location Code:
Initials of Data Inputter:
Appendix A to Questions 20b. & 39b.
If your company is currently exporting, please indicate the countries to which your company exports: (Mark all that apply)
Asia Africa Caribbean Central America North America
Afghanistan
Algeria
Anguilla
Belize
Bermuda
Bahrain
Angola
Antigua & Barbuda
Costa Rica
Mexico
Bangladesh
Benin
Aruba
El Salvador
Canada
Belarus
Botswana
Bahamas
Guatemala
Bhutan
Brunei
Burma
Cambodia
Burkina Faso
Burundi
Cameroon
Cape Verde
Barbados
Virgin Islands (British)
Cayman Islands
Cuba
Honduras
Nicaragua
Panama
South America
China
East Timor
Central African Republic
Chad
Dominica
Dominican Republic
Europe
Argentina
Bolivia
Georgia
Comoros
Grenada
Austria
Brazil
Hong Kong
Congo
Haiti
Azerbaijan
Chile
India
Democratic Republic of Congo
Jamaica
Albania
Colombia
Indonesia
Cote d'Ivoire
Montserrat
Armenia
Ecuador
Iran
Djibouti
Netherlands Antilles
Belgium
Guyana
Iraq
Egypt
St. Kitts and Nevis
Bosnia-Herzegovina
Paraguay
Israel
Equatorial Guinea
St. Lucia
Bulgaria
Peru
Japan
Eritrea
St. Vincent and Grenadines
Croatia
Suriname
Jordan
Ethiopia
Trinidad and Tobago
Cyprus
Uruguay
Kazakhstan
Gabon
Czech Republic
Venezuela
Korea, North
Gambia
Denmark
Oceania
Korea, South
Ghana
Estonia
Australia
Kuwait
Guinea
Finland
New Zealand
Kyrgyzstan
Guinea-Bissau
France
Cook Islands
Laos
Kenya
Germany
Fiji
Lebanon
Lesotho
Greece
Kiribati
Macau
Liberia
Hungary
Marshall Islands
Malaysia
Libya
Iceland
Nauru
Maldives
Madagascar
Ireland
Palau
Micronesia
Malawi
Italy
Papua New Guinea
Mongolia
Mali
Latvia
Samoa
Nepal
Mauritania
Liechtenstein
Solomon Islands
Oman
Mauritius
Lithuania
Tonga
Pakistan
Morocco
Luxembourg
Tuvalu
Philippines
Mozambique
Macedonia
Vanuatu
Qatar
Namibia
Malta
Russia
Niger
Moldova
Saudi Arabia
Singapore
Nigeria
Rwanda
Monaco
Montenegro
Other
Sri Lanka
Syria
Sao Tome and Principe
Senegal
Netherlands
Norway
Subcontractor for Exporter
Tajikistan
Seychelles
Poland
_____________________
Taiwan
Sierra Leone
Portugal
Thailand
Somalia
Romania
Turkey
South Africa
Serbia
Turkmenistan
Sudan
Slovak Republic
United Arab Emirates
Swaziland
Slovenia
Uzbekistan
Tanzania
Spain
Vietnam
Togo
Sweden
Yemen
Tunisia
Uganda
Zambia
Zimbabwe
Switzerland
Turkey
Ukraine
United Kingdom
Vatican City
Please note: The estimated burden for completing this form is 18 minutes. You are not required to respond to any collection information unless it displays a currently valid OMB
approval number. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3
rd
Street, SW, Washington, DC 20416, and to: Desk Officer SBA, Office
of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.
SBA Form 641 (10/24/2017)
3